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A Radiographic Study of Biomechanical Relationship Between the Achilles Tendon and Plantar Fascia

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A Radiographic Study of Biomechanical Relationship Between the Achilles Tendon and Plantar Fascia Hindawi BioMed Research International Volume 2020, Article ID 5319640, 6 pages https://doi.org/10.1155/2020/5319640 Research Article A Radiographic Study of Biomechanical Relationship between the Achilles Tendon and Plantar Fascia Genrui Zhu, Zhifeng Wang, Chengjie Yuan, Xiang Geng, Chao Zhang, Jiazhang Huang, Xu Wang , and Xin Ma Department of Orthopedics, Huashan Hospital, Fudan University, No. 12, Middle Wulumuqi Road, Jingan District, Shanghai, China Correspondence should be addressed to Xu Wang; [email protected] Received 14 September 2019; Revised 12 December 2019; Accepted 25 January 2020; Published 18 February 2020 Academic Editor: Ali Nokhodchi Copyright © 2020 Genrui Zhu et al. 0is is an open access article distributed under the Creative Commons Attribution License, which permits unrestricted use, distribution, and reproduction in any medium, provided the original work is properly cited. Background. Previously, scholars have concluded that the Achilles tendon and the plantar fascia were closely biomechanically related, although there is little clinical evidence of the relationship between the two. To investigate the biomechanical relationship between the Achilles tendon and the plantar fascia, the author used standing lateral ankle radiographs of patients with insertional Achilles tendonitis to determine the biomechanical relationship between the Achilles tendon and plantar fascia. Methods. 0e author collected standing lateral ankle radiographs from patients with insertional Achilles tendonitis who accepted surgical treatment in the author’s hospital from March 2009 to July 2018. According to whether there were bone spurs on the posterior side of the calcaneus, patients were divided into group A (spur present on the posterior side) and group B (spur not present on the posterior side). 0e positive rates of spurs on the plantar side of the calcaneus were determined in group A and group B. 0e chi- square test was used to compare the measurement results between the two groups. Results. In group A, 13 heels were positive for calcaneal bone spurs, and the positive rate was 65.0%. In group B, 3 heels were positive for plantar calcaneal spurs, and the positive rate was 12%. Among all 16 patients with positive plantar calcaneal spurs, 13 had posterior calcaneal spurs (accounting for 81.3%), and 3 had negative results, accounting for 18.7%. 0ere was a significant difference between the results in groups A and B (P < 0:05). Conclusion. 0ere is a relationship between posterior calcaneal spurs and plantar calcaneal spurs in patients with insertional Achilles tendonitis, which can be inferred as resulting from the increasing tension in the biomechanically complex relationship between the Achilles tendon and the plantar fascia. 1. Introduction the risk of Achilles tendon degeneration and insertional Achilles tendonitis [10]. Further, if the Haglund deformity, Heel pain includes pain on the plantar side of the calcaneus insertional Achilles tendonitis and retrocalcaneal bursitis ap- and in the posterior heel [1]. Plantar heel pain is often caused pear, then it is known as Haglund syndrome. by plantar fasciitis, with its typical symptom of pain at the In the current clinical work, it was anecdotally found that medial calcaneal tubercle that is aggravated after standing patients with plantar heel pain who were diagnosed with for long periods of time or running [2–5]. Bone spurs at the plantar fasciitis often presented with posterior heel pain. Due medial calcaneal tubercle is a typical finding on the X-rays of to an anatomical connection between the Achilles tendon, the plantar heel pain patients, and they can be the mechanical plantar fascia, and the calcaneal, we proposed a hypothesis factors inducing the occurrence of plantar fasciitis [5–7]. that the Achilles tendon, the plantar fascia, and the calcaneal Posterior heel pain is often caused by insertional Achilles were three parts of a biomechanical complex. And in the tendonitis, often combined with the Haglund deformity [8, 9]. high-tension state of this complex, like in the insertional 0e Haglund deformity is an abnormal cystic projection above Achilles tendinitis patients, not only the pain appeared on the the posterior calcaneus, which can cause a high pressure state both sides of calcaneal, but the compensatory bone spurs on its rear structure, lead to retrocalcaneal bursitis, and increase caused by high tension were found bilaterally also [11, 12]. 2 BioMed Research International In the past, the development of bone spurs on both Since Haglund deformity was believed to have a rela- sides of the calcaneus in patients with Achilles tendinop- tionship with insertional tendinitis, the following various athy and Haglund syndrome has been observed. Fiamengo measurements were also made: the Fowler-Philip angle, as et al. found that the rate of spurs on the posterior side of the shown in Figure 2, the parallel pitch lines, as shown in calcaneus in patients with Achilles tendinopathy reached Figure 3, and the presence of a posterior calcaneal spur, as 44% and the rate of plantar spurs in the same population shown in Figure 1 [17–19]. 0ere was a flowchart to show was 6.3% [13]. In a population with Haglund syndrome, the how the study was conducted, as shown in Figure 4. rate of posterior calcaneal spurs was 57% and the rate of 0e chi-square test was applied to compare the mea- plantar spurs was 16% [14]. Menz et al. found that 55% of surements between the two groups, with the P value set at patients had radiographic evidence of plantar spurs, among 0.05 for statistical significance. whom 56% had an Achilles tendon spur [15]. To further clarify the relationship between plantar spurs and Achilles 3. Results tendinopathy, Vulcano et al. found that 41.9% of the 785 patients diagnosed with Achilles tendinopathy in outpa- According to the inclusion and exclusion criteria, 43 patients tient clinics had plantar spurs [16]. with insertional Achilles tendonitis were enrolled in the Although the rates of bone spurs on the posterior and study group, with 2 having bilateral Achilles tendonitis, so a plantar sides of the calcaneus were observed in previous total of 45 cases of insertional Achilles tendonitis were studies, these studies did not explore the possibility of spurs collected, as shown in Table 1. Of the 43 patients, 37 were appeared simultaneously on both sides of calcaneal in the men (86%), and 6 were women (14%), with an average age of high-tension state of this biomechanically complex. 40.7 (range 15 to 69) years. 0ere were 15 left heels (34.9%), 0e aim of this study was to demonstrate the biome- 26 right heels (60.5%) and 2 bilateral heels (4.7%). chanical relationship between the Achilles tendon and the 0ere were 19 subjects with 20 heels in group A, which plantar fascia by comparing the probability of developing consisted of 14 men and 5 women, with an average age of bilateral calcaneal spurs with that of developing unilateral 46.0 ± 12.4 years (range from 17 to 69 years old). 0ere were calcaneal spurs in the high tension state. So the author ret- 24 subjects with 25 heels in group B, which consisted of 23 rospectively reviewed patients with insertional Achilles ten- men and 1 woman, with an average age of 36.9 ± 15.0 years dinitis who received surgical treatment in the author’s hospital (range from 15 to 65 years old). and analyzed the bone structure data from standing lateral In group A, calcaneal plantar spurs were present in ankle radiographs. 65.0% (13 out of 20) of the heels with calcaneal posterior spurs, while in group B, calcaneus plantar spurs were present 2. Method in 12.0% (3 out of 25), as shown in Figure 5. Calcaneal plantar spurs were found in 16 out of 45 heels, of which 13 0e study was a retrospective radiographic review of patients had posterior spurs (81.3%), as shown in Figure 6. However, with insertional Achilles tendinitis who were admitted for when the plantar spurs were negative (29 out of 45 heels), operations at the orthopedic department in Huashan there were only 24.1% of heels (7 out of 29) presenting Hospital of Fudan University (Shanghai, China) from March posterior spurs, as shown in Table 2. 0ere were significant 2009 to July 2018. 0e inclusion criteria for the study differences between the two groups (P < 0:05). 0e rate of consisted of patients with a diagnosis of insertional Achilles spurs presenting on both sides of calcaneus was 28.9% (13 tendinitis. 0e diagnosis was made by the senior author out of 45). based on his clinical examination and radiographic review In 45 cases of insertional Achilles tendonitis, the positive and was reassured by surgical pathology. All patients had rate of parallel pitch lines was 75.6% (34 out of 45). 0e mean lateral view standing radiographs taken of the ankle. Fowler-Philip angle was 51.39 ± 7.85 degrees. 0ere was only Patients were excluded from the study group if they had one heel in which the Fowler angle was more than 75 degrees previous Achilles tendon surgery or had noninsertional (88°). Achilles tendinitis. 0e present study was approved by the Institutional Review Board of our institutions, and informed 4. Discussion consent was obtained from all participants. According to whether there were bone spurs on the Pain in the heel includes pain on the plantar side of the posterior side of the calcaneus, patients were divided into calcaneus and posterior heel pain [9, 20, 21]. In the current group A (spur was present on the posterior side) and clinical work, it was anecdotally found that patients with group B (spur was not present on the posterior side), as plantar heel pain often presented with posterior heel pain shown in Figure 1. 0en, the author evaluated and [22].
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